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Explanation of Benefits (EOB), explained

 

KEY TAKEAWAYS:

What to know about EOBs

In the world of health insurance, there are many terms and abbreviations that are important, but can be hard to understand. One example is EOB, which stands for Explanation of Benefits. Okay, so what’s an EOB? (Thank you for asking.)

After you’ve gone to a doctor or had a medical procedure, you usually get an Explanation of Benefits in the mail from your insurance company. In fact, you may receive more than one, even if you only had one event or procedure. That’s because each provider, service, or facility involved in your treatment may result in an EOB.

A typical EOB includes the following:

  • General service details, including the date of the service, the claim or reference number, and the name of the doctor or facility
  • How much the provider is charging and what each charge is for
  • What’s covered by your insurance plan — specifically, how your insurance benefits have been applied
  • The bill amount, the amount your insurance covers, and the “patient responsibility,” which is the amount the provider expects you to pay for the service. These three pieces of information are key to understanding what you actually owe

Is an EOB a bill?

Keep in mind an EOB is not a bill, it’s a recap of how your insurance company is processing a claim from a provider. You will likely see a bill from your provider soon, and unless they apply additional discounts, the amount listed as “patient responsibility” is what you may be asked to pay.

Why should you examine an EOB if it’s not a bill? By reading it while the experience is still fresh in your mind, you can make sure everything is accurate and there’s nothing unanticipated — now, or when the bill comes.

A potential EOB pain point: out-of-network health care costs

Sometimes, medical procedures involve services performed by providers other than your doctor — like anesthesiologists, pathologists, surgical assistants, and others. These providers may operate separately from your primary provider and may bill your insurance separately.

If you receive an EOB that includes out-of-network charges that seem excessive, it may be a mistake with a fairly simple explanation, such as:

  • A referral from your doctor for another provider/specialist/service was missing
  • An out-of-network provider submitted a claim before your main doctor or facility did
  • An emergency situation was processed as a non-emergency

There are some legitimate reasons for out-of-network charges. But whether the out-of-network charges are correct or not, getting clobbered with a big fee you didn’t expect can be distressing. Don’t panic. We can help you get to the bottom of it.

What to do if your EOB includes out-of-network health care charges

Naviguard® was created because health care costs can be confusing — and expensive. If your EOB includes unexpected charges for an out-of-network provider, consider contacting Naviguard. One third of privately insured people in the U.S. has received an unexpected balance medical bill from an out-of-network provider.1 Our job is to help resolve these issues and prevent them in the future.

Our experts have helped tens of thousands of UnitedHealthcare members navigate difficult balance medical bills with significant success. This includes more than 350,000 cases, engaging with more than 5,900 providers across the U.S. in over 170 specialties.*

If your UnitedHealthcare plan includes Naviguard, our services are available to you at no charge. Put our expertise to work. We’re here for you.

*Based on Naviguard’s engagement with its members from January 2021 through October 2023.

 

RESOURCES

REFERENCES

  1. Khazan, O. (2023) The agony of medical bills. The Atlantic
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